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10/12/2009 16:01 608-267-1540 DANE CO PLANNING PAGE 02/03
<br /> - .ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME -
<br /> n __ CI Zoning Status; CUP;
<br /> owN(FR AD • S •u bar,Strool,Clry,Stoto ZIP) Deed Restriction; CSM
<br /> • ie. e 1 ■ ' d VmSI A. I G 31 Variance(# )
<br /> HOME PH N CELL PHONE E•MAILADDRESS
<br /> P V .V-1 . '13 UI ' J' ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAM '
<br /> �
<br /> VC-1•tA e P Sniss L]..c ❑ Site Plan including location
<br /> AGENTADDRESS� CONTRACTOR AD RESS W of well/septic
<br /> • Plt
<br /> (City,Slate,ZIP) (city,stale,zip) ❑ Setbacks
<br /> Oat Al ills, WI 53x51
<br /> PHONE PHONE 4 ❑ Site Plan approval from
<br /> a� (0. 3ffl.3 applicable township.
<br /> E•MAII.ADDRESS E-MAIL ADDRESS
<br /> ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dbne.wL.0-./) ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:
<br /> ❑ PARCEL frontage drawn to scale.
<br /> NUMBER
<br /> TOWNSHIP: SECTION:
<br /> 1/4: 1/41/4: ❑ Driveway permits
<br /> ADDRESS; (state,county,town)
<br /> ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCKILOT (public,private)
<br /> ;�iI�R 1,t fr I' 1
<br /> PROPOSED PROJECT INFORMATION 1 I I' I !y� I t �IIFt, r(It r
<br /> PR%'CT DESC•PTION: I / I 11 r,''l ii I Ell `i� i )l� ' i
<br /> �� ► I k�. . A . liii w •i I , "�I' II1' I
<br /> . ❑This project is a new building or structure. ' oq' I• 41?' ; I' ; i°
<br /> �r�I'1tf ll(Ijt it {6111p4,��i1 t7 '
<br /> This project is an addition/alteration to an existing buildin or structure. ).. }N.i.rt;. '� �` rr(w,i I� ilk f SANITARY SERVICE: PERMIT NUMBER: � 1L; r1
<br /> ' I;Vir
<br /> ❑SEWER •O SEPTIC }n r
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not Inducting basement) ��, I ` i t,it ':4 '4:4,1';''r ',
<br /> �N
<br /> X19 1. Q ' o L fifIIr I4I
<br /> it?t I, f�'� , I 1 I•
<br /> AREA TO NEAREST SQUARE FOOT: ' trill*1 C' ql 11� '' '; al(Outside dimensions including Unfinished area, attached garages and above grade decks or porches) ;e+ j'kd ,., A A•1� 11 P} `,,:,;11.i
<br /> BASEMENT: 1ST FLOOR: I ,y� 9 4,41,raj 4 I ti I I r J.
<br /> 4, TOTAL SQUARE FOOTAGE: ,l, r 1 J' , I, , °} N,(i, .,��ri m� I,. ,k I.
<br /> 2ND FLOOR: 3RD FLOOR: ;/I 'lla ,( Ih1a' 1(r 1 1 ,,; ICy;�1�y '�
<br /> l'I410q . ..t,' 4 ,its , I,I
<br /> (II
<br /> irk I' t.. l I.I 'i)
<br /> n I��w 1�fl',. �I.,.� J,FJ4• »IilgNir}'i,�.l u.iA.
<br /> ESTIMATED CONSTRUCTION COST: ,.. �I ,.1 p.m itri 1 ,,E
<br /> (Please round to nearest dollar) s}a�1illkilig ,._9.IIL:,igiai 1l lth:, 41 iti
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 0 N l.d'D n't know
<br /> 2, Is there a wetland or floodplain on or near the property? ❑Yes ❑No fV, Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? Zes ❑No
<br /> 4, Has there been a zoning permit issued for this property in the past 5 years? DYes ❑No d Doh`4 It j 1]
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal ft ) (leave blank if none)
<br /> 6. Is a location survey required? (see reverse) CI Yes aeNo ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes 'No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Beck) --► •-► -•o.
<br /> 541-112(UBO)
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